Impact of CFTR modulator therapy on body composition as assessed by thoracic computed tomography: A follow-up study

OBJECTIVE

Treatment with cystic fibrosis transmembrane conductance regulator (CFTR) modulators in individuals with cystic fibrosis (CF) has brought a significant change in forced expiratory volume in 1 second (FEV1) and clinical parameters. However, it also results in weight gain. The aim of our study is to evaluate the effect of CFTR modulator treatment on body composition, measured by computed tomography (CT).

METHODS

Adult subjects with CF under follow-up at La Princesa University Hospital were recruited. All of them were on elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA) treatment. Body composition analysis was conducted using CT scans and an open-source software. The results were then compared with bioimpedance estimations, as well as other clinical and spirometry data.

RESULTS

Our sample consisted of 26 adult subjects. The fat mass compartments on CT scans correlated with similar compartments on bioimpedance, and normal-density muscle mass exhibited a strong correlation with phase angle. Higher levels of very low-density muscle prior to treatment were associated with lower final FEV1 and less improvement in FEV1 after therapy. We observed an increase in total body area (P < 0.001), driven by increases in total fat mass (P < 0.001), subcutaneous fat (P < 0.001), visceral fat (P = 0.002), and intermuscular fat (P = 0.022). The only muscle compartment that showed an increase after treatment was very low-density muscle (P = 0.032).

CONCLUSIONS

CT scans represent an opportunity to assess body composition on CF. Combination treatment with CFTR modulators, leads to an improvement in FEV1 and to an increase in body mass in all compartments primarily at the expense of fat mass.

Continuous Glucose Monitoring as an Additional Tool in Early Cystic Fibrosis-Related Diabetes Monitoring and in Evaluation of Short-Term Sitagliptin Response

Cystic fibrosis-related diabetes (CFRD) is a complication associated with a negative prognosis in patients with cystic fibrosis (CF). Although the oral glucose tolerance test (OGTT) is the widely recommended screening test for CFRD diagnosis, continuous glucose monitoring (CGM) is increasingly considered a useful and easy-to-perform test for diagnosis and follow-up in clinical practice. Regarding CFRD treatment, although insulin is the classic approved pharmacological option, incretins could also be a helpful alternative in early stages. CGM could be also a useful tool to measure the early response to this therapy.

METHODS

We studied 25 CF patients with abnormal OGTT results and compared glucose and insulin levels during the OGTTs with CGM results as a tool for early CFRD diagnosis. In addition, we evaluated glycaemic control with CGM before and after treatment with sitagliptin.

RESULTS

A correlation was found between lower plasma insulin levels during the OGTTs and higher average sensor glucose (p = 0.009) and hyperglycaemic excursions (p = 0.017). The CGM data on sitagliptin treatment (n = 25) showed an average glycaemic improvement from 124.2 to 117.2 mg/dL (p = 0.002) with a 5.6-point standard deviation of glucose decrease (p < 0.001). Hyperglycaemic excursions ≥200 mg/dL diminished 57.1% (p = 0.021). Both time in range and time above 180 mg/dL improved during treatment (p = 0.036 and p = 0.006, respectively).

CONCLUSION

CGM is a useful tool that offers valuable information for both the diagnosis and the management of CFRD. Lower plasma insulin levels during OGTTs are associated with a poor ambulatory glucose profile in CGM. Sitagliptin could play an important role in the treatment of the early stages of CFRD.

New evidence in severe pneumonia: imipenem/ cilastatin/relebactam

Imipenem combined with beta-lactamase inhibitor relebactam (IMI/REL) has an extensive bactericidal activity against Gram-negative pathogens producing class A or class C beta-lactamases, not active against class B and class D. The phase 3 clinical trial (RESTORE-IMI-2), double-blind, randomized, evaluated IMI/REL vs. piperacillin-tazobactam (PIP/TAZ) for treatment of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), demonstrated non-inferiority at all-cause mortality at 28 days (15.9% vs 21.3%), favorable clinical response at 7-14 days end of treatment (61% vs 59.8%) and with minor serious adverse effects (26.7% vs 32%). IMI/REL is a therapeutic option in HAP and VAP at approved dosage imipenem 500 mg, cilastatin 500 mg and relebactam 250 mg once every 6h, by an IV infusion over 30 min.

Filamentous fungi in the airway of patients with cystic fibrosis: Just spectators?

BACKGROUND

There are important advances in the management of bacterial infection in patients with cystic fibrosis (CF), but there are many gaps in the field of fungal infections.

AIMS

The aim of this study was to analyse whether chronic respiratory filamentous fungal colonization had clinical impact and whether antifungal treatment can change the disease.

METHODS

The prospective, bicentric and descriptive study was carried out within a 3-year follow-up period, with four-month periodicity medical controls. Adult patients from two CF units of tertiary hospitals were included. Clinical, microbiological, analytical and spirometric variables were collected. Quality of life was evaluated in a subgroup, using the Spanish version of the Revised Cystic Fibrosis Quality of Life Questionnaire (CFQ-R). To statistically analyze the evolution of forced expiratory along time (volume of air blown out in 1 second -FEV₁-) and the forced vital capacity (FVC), mixed linear models were carried out.

RESULTS

From the ninety-eight patients under study, 40 suffered chronic filamentous fungal colonization. The presence of filamentous fungi in airway was associated to an annual fall of FEV₁ and FVC of 0.029 and 0.017 litres, respectively (p<0.001). In addition, worse quality of life based on CFQ-R, significant when concerning physical condition and emotional state, was also linked with the fungal colonization. Protocolized antifungal therapy, nebulized or oral, improved FEV₁ in 0.023 and 0.024 litres per year, respectively (p<0.001).

CONCLUSIONS

Chronic filamentous fungal colonization in patients with CF is associated with a significant annual decline of lung function that persists over time. Chronic antifungal therapy slows down this progression, mainly in the patient with more advanced disease.

Spanish Guidelines on the Evaluation and Diagnosis of Bronchiectasis in Adults

In 2008, the Spanish Society of Pulmonology (SEPAR) published the first guidelines in the world on the diagnosis and treatment of bronchiectasis. Almost 10 years later, considerable scientific advances have been made in both the treatment and the evaluation and diagnosis of this disease, and the original guidelines have been updated to include the latest scientific knowledge on bronchiectasis. These new recommendations have been drafted following a strict methodological process designed to ensure the quality of content, and are linked to a large amount of online information that includes a wealth of references. These guidelines cover aspects ranging from a consensual definition of bronchiectasis to an evaluation of the natural course and prognosis of the disease. The topics of greatest interest and some new areas are addressed, including epidemiology and economic costs of bronchiectasis, pathophysiological aspects, the causes (placing particular emphasis on the relationship with other airway diseases such as chronic obstructive pulmonary disease and asthma), clinical and functional aspects, measurement of quality of life, radiological diagnosis and assessment, diagnostic algorithms, microbiological aspects (including the definition of key concepts, such as bacterial eradication or chronic bronchial infection), and the evaluation of severity and disease prognosis using recently published multidimensional tools.

Depression and anxiety symptoms in Spanish adult patients with cystic fibrosis: associations with health-related quality of life

BACKGROUND

Cystic fibrosis (CF) is a chronic disease with an impact on the quality of life. Self-reported symptoms of depression and anxiety were assessed in the Spanish cohort of the International Epidemiological Study on Depression and Anxiety in patients with CF (International Depression-Anxiety Epidemiological Study) and their relationship with health status and health-related quality of life (HRQoL) was evaluated.

METHODS

This cross-sectional study recruited adult patients with CF at 10 Spanish centers. Patients completed the Hospital Anxiety and Depression Scale (HADS) and the Revised Cystic Fibrosis Questionnaire. Demographic and health data were recorded from medical charts. Logistic regression was used to determine the predictors of elevated symptoms of depression and anxiety (HADS≥8).

RESULTS

Of the 336 participants recruited (mean age, 28.1years; 48.2% women), 41 (12.2%) had elevated depression-related scores, and 100 (29.7%) had elevated anxiety-related scores (HADS≥8). After adjusting for confounders, only less education, intravenous antibiotics, psychiatric medications and psychotherapy were significantly associated with elevated psychological symptoms. Specifically, regardless of lung function, patients who were depressed or anxious reported worse HRQoL.

CONCLUSIONS

The prevalence of elevated symptoms of depression and anxiety was high in Spanish adult patients with CF, and these symptoms were associated with a decreased HRQoL.

Long-term safety and efficacy of tobramycin in the management of cystic fibrosis

Cystic fibrosis (CF) is a fatal inherited disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene whose mortality is conditioned by a progressive decline in lung function. Bacterial infections play a key role in this decline. Chronic bacterial infection in CF patients varies over time and the presence of Pseudomonas aeruginosa in sputum is a marker of poor prognosis. P. aeruginosa is eradicated from the airways using inhaled antibiotics administered in various formulations and devices. Antipseudomonal antibiotics have extended the survival of CF patients to 40 years. Tobramycin is a bactericidal aminoglycoside antibiotic with demonstrated activity against gram-negative microorganisms. Initially, the drug was administered as an inhaled parenteral solution. Subsequently, a specific tobramycin inhalation solution was developed. PulmoSphere™ technology enables dry tobramycin powder to be formulated for inhalation (tobramycin inhalation powder) using a small and portable capsule-based breath-activated device (T-326). Chronic colonization by P. aeruginosa is the main indication for aerosol antibiotic therapy. The American Cystic Fibrosis Foundation, European guidelines, and Spanish consensus guidelines provide different recommendations for eradication.

Lymphangioleiomyomatosis: a study of 72 patients from the Spanish registry

BACKGROUND

Pulmonary lymphangioleiomyomatosis (LAM) is a rare lung disease that almost exclusively affects young women of childbearing age. The true incidence and prevalence of LAM are unknown. This study was conducted to evaluate the characteristics of lymphangioleiomyomatosis in Spain.

METHODS

Over a 2-year period, a questionnaire designed for this study was collected. This questionnaire included sociodemograhic, clinical, radiological and functional data. Information about the study and this questionnaire were both sent by e-mail to all the participants of the interstitial disease registry of 2004.

RESULTS

Seventy-two patients, all of whom were women, were included in the registry, with a mean age of 44.56 +/- 11.1 yr. Sixty-three patients (87.5%) presented the sporadic LAM and 9 (12.5%) presented LAM associated with tuberous sclerosis (LAM-TS). LAM diagnosis was confirmed with an open lung biopsy in 57 patients (79.2%) and was performed with thoracic HRCT compatible with LAM diagnosis in the other 15 cases. The most frequent symptom was dyspnoea (90%) followed by cough (44.4%). Almost 40% of patients presented renal angiomyolipomas in the study and the most frequent spirometric pattern was obstructive in more than half of the patients. Most patients with LAM-TS (88.8%) had renal angiomyolipomas compared with 31.7% in the sporadic LAM group.

CONCLUSION

The characteristics of the Spanish population affected with LAM are similar to those of other countries. Most patients were symptomatic, had a history of previous pneumothorax and presented abnormal radiological findings and pulmonary function tests.

[Predictive factors for survival in patients with idiopathic pulmonary fibrosis]

BACKGROUND AND OBJECTIVE

To determine the median survival and determinants of survival in patients with idiopathic pulmonary fibrosis (IPF).

PATIENTS AND METHOD

We retrospectively evaluated 29 IPF patients who died in the pneumology department between 2001 and 2006. Data from the time of diagnosis until death were analysed. Determinants of survival including age at diagnosis, gender, history of cigarette smoking, fibrosis-emphysema association, and lung function tests were analysed.

RESULTS

The mean age at diagnosis was 69.7, 16 patients were men (55.2%). The median survival time, from the time of diagnosis, was 28.47 months (20.44-36.5 IC95%). There was a significant difference in survival between age groups. The median survival time in patients older than 65 years was 22.40 months and in patients younger than 65 years it was 56.37 months (p<0.001). There was no significant difference in survival when other determinants of survival. were evaluated.

CONCLUSION

The median survival of IPF patients is low. It is necessary to continue investigating to find more effective and selective therapeutic strategies.

[Polymyositis and interstitial lung disease with a favorable response to corticosteroids and methotrexate]

Polymyositis is a rare collagen disease that can involve the lungs. Between 5% and 30% of patients with polymyositis present interstitial lung disease at diagnosis or during the course of disease. Onset is usually insidious and involves dyspnea and nonproductive cough. Several histopathological findings are associated with polymyositis and the most common is nonspecific interstitial pneumonia. The prognosis of interstitial lung disease associated with polymyositis is better than that of idiopathic pulmonary fibrosis, since most patients respond to treatment with corticosteroids and immunosuppressants. We report the case of a 60-year-old woman with dyspnea and muscle weakness who was diagnosed with polymyositis and interstitial lung disease (radiography indicated possible nonspecific interstitial pneumonia). The patient responded well to prednisone and methotrexate.

[Efficiency of the home intravenous antibiotics treatment in cystic fibrosis]

BACKGROUND AND OBJECTIVE

The objective of our study was to determine the costs saving with the implementing of a home intravenous antibiotic treatment (HIVAT) program for patients with cystic fibrosis and to compare it with the conventional system (inpatient).

PATIENTS AND METHOD

Consecutive patients in an adults cystic fibrosis unit were selected who received some days of HIVAT, between January 2002 and December 2004. For the analysis of costs saving of the HIVAT, we used the difference between the total costs of the avoided stay days and the costs generated by the domiciliary therapy (drugs, expendable equipment) and by the ambulatory medicine unit in case the patients were not hospitalized. All patients received a therapy with an intravenous antibiotic for a minimum of 14 days. All these data were provided by the accounting service of the hospital with the aid management Clinical Financier Program (GECLIF).

RESULTS

22 patients with cystic fibrosis needed 85 intravenous antibiotics treatments during the 3 years of the study, of which: 43 cycles were completely domiciliary, 14 inpatient and 28 were combined (hospital and home). The 71 cycles of HIVAT originated 909 days at home, with an average (standard deviation) of 12.80 (4.18) days and 43 treatments in ambulatory medicine unit. The home antibiotic treatments that originated greater cost (3,964.34 Euro) was meropenem (1 g/6 h) i.v. with linezolid (600 mg/12 h) via oral combination during 14 days, and in second place the association of ceftazidime, tobramycine and linezolid, whose cost in cycle of 14 days was of 2464.84 Euro. The average saving cost in the 3 years of study was of 2,647.29 Euro by each cycle of HIVAT and global 197,689.78 Euro.

CONCLUSIONS

HIVAT obtained important sanitary costs saving and this was greater every year, not due to the increase of days at home, but due to the rising cost per day of hospital stays every new year.

[Cystic fibrosis in adults: inter- and intraobserver agreement for the Brasfield and Chrispin-Norman chest radiography scoring systems and correlation with clinical data and spirometry]

OBJECTIVE

Most chest radiography scoring systems for patients with cystic fibrosis have been developed for children but are also used for adults. Our aim was to evaluate the intra- and interobserver variability of 2 radiographic scoring systems in adults with cystic fibrosis and to assess the correlation of these systems with clinical and spirometric parameters.

PATIENTS AND METHODS

The chest x-rays of 24 adult patients with cystic fibrosis were compared using 2 scoring systems (Brasfield and Chrispin-Norman). The x-rays were scored by 2 radiologists and reevaluated 4 months later by 1 of the 2 observers. Intra- and interobserver agreement was assessed using the intraclass and Pearson's correlation coefficients. The radiographic scores were compared to lung function tests and other clinical data.

RESULTS

Both intra- and interobserver agreement were high (r > or = 0.9 and the intraclass correlation coefficient > or = 0.85 with both systems for both samples). Both scoring systems correlated with spirometry results: forced expiratory volume in the first second (FEV1) (r = 0.64 and r = 0.55), FEV1% (r = 0.75 and r = 0.72), and the percentage of forced vital capacity in relation to the predicted value (r = 0.63 and r = 0.056). We found no association between scoring system and sex, age, or body mass index.

CONCLUSIONS

Assessment of chest radiographs of adult patients with cystic fibrosis by the Brasfield and Chrispin-Norman scoring systems shows good intra- and interobserver agreement. Both systems correlate well with lung function variables, especially FEV1.

[Nontuberculous mycobacteria in patients with cystic fibrosis]

OBJECTIVE

Patients with cystic fibrosis are at great risk of infection by nontuberculous mycobacteria from the environment because of certain predisposing factors such as bronchiectasis, malnutrition, and diabetes. The aim of this study was to analyze the mycobacterial content of sputum smears and cultures from adult patients with cystic fibrosis attended at a specialized unit for adults from March 1997 through December 2001.

PATIENTS AND METHODS

Sputum samples were collected prospectively according to a protocol applied at each visit, and during most exacerbations staining and culture for mycobacteria were ordered in addition to the usual cultures for bacteria and fungi. A tuberculin test was performed at the end of the study.

RESULTS

Twenty-eight patients (16 men) with cystic fibrosis were enrolled. The mean (SD) age was 25.3 (6.7) years. A total of 251 samples were cultured (range in number of samples per patient, 1-31). The mean period of follow up was 40.3 (22.1) months. The sputum smear was positive in 29 cases (4 patients); the culture was positive in 7 patients. More than 3 samples were positive in only 4 patients. Mycobacterium abscessus was isolated in 3 cases, Mycobacterium avium complex in 2 and Mycobacterium simiae in 1 and other an unidentified rapid growth Mycobacterium species. The Mantoux test was positive in 5 patients. Two of the 4 patients in whose samples mycobacteria were isolated repeatedly required treatment.

CONCLUSIONS

The prevalence of nontuberculous mycobacterial infection is high in patients with cystic fibrosis. Staining and culture for mycobacteria should be carried out regularly and whenever exacerbation of pulmonary symptoms cannot be attributed to bacteria usually found in such patients. Patients with recurrent isolations of mycobacteria should be monitored closely.

Efectividad en la aplicación de tres protocolos de prevención y tratamiento de la osteoporosis en pacientes adultos con fibrosis quística

BACKGROUND AND OBJECTIVE

Reduction of bone mineral density (BMD) is a complication of cystic fibrosis (CF) which is observed in parallel to the increment of life expectancy in these patients. The aim of this study was to analyze the evolution of BMD following the application of a protocol for the prevention and treatment of osteoporosis.

PATIENTS AND METHOD

We performed a multidisciplinary prospective study in 21 adult patients with CF with a mean age of 24.3 (r: 19-44) years. We evaluated BMD results depending on the treatment schedule, and the annual relative change of BMD percentage was correlated with changes observed in respiratory function, corporal mass index (CMI), Brasfield radiologic score and Shwachman clinical score for a 3 years follow up period. Three regimens of treatment were applied: general measurements, supplementation of calcium and vitamin D, and 10 daily mg of alendronate plus calcium and vitamin D supplements.

RESULTS

Basal assessment showed that 14.2% of CF patients had a marked diminution of bone mass with respect to an age and sex matched control population, with a Z score of < -2 DE in lumbar vertebral and/or total femur. Another 38% showed a lessening of Z score between -1 and -2.5 DE. We observed a progressive annual reduction of BMD in all the anatomic areas analyzed: -0.52% (1.87) in lumbar spine, -1.17% (1.91) in total femur and -2.16% (2.65) in neck femur. The hip BMD annual decrement was related to that observed in FEV1. Only patients treated with alendronate did not suffer progressive BMD lose. Treatment with a combination of calcium, vitamin D and alendronate was more efficient in hip BMD than calcium plus vitamin D alone (p < 0.05). Also, this combination was better than no treatment at hip and femoral neck levels (p < 0.05).

CONCLUSIONS

Our work confirms that Spanish young adults patients with CF show low control matched BMD, and that it even worsens at follow-up. This decrement is not adequately halted with preventive treatment with supplements of calcium and vitamin D, and only patients treated with alendronate show increments of their BMD.

[Home intravenous antibiotic treatments in cystic fibrosis units of Madrid]

BACKGROUND AND OBJECTIVE

A descriptive study of the home intravenous antibiotic treatment (HIVAT) course in cystic fibrosis (CF) units of Madrid in an 18 month period. Different patient features were recorded, antibiotherapy, intravenous access, complications and their resolutions. We accessed the improvement of the pulmonary function, forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) at the end of the treatment.

PATIENTS AND METHOD

For an 18 months period (January 2002-June 2003) the patients with CF who received HIVAT and fulfilled the previously fixed criteria were included. The next clinic variables were collected: age, sex, bacterial colonization of respiratory tree, pancreatic function and pulmonary function in steady phase, before and after HIAT.

RESULTS

56 patients, 31 male and 25 female, were given 90 courses of HIAT (34 patients received only one course). Mean age was 20.06 (8.07) years. 57.1% of the patients were colonized by Pseudomonas aeruginosa. The most frequently used antibiotics were ceftazidime and tobramycin. Courses of treatment lasted a mean of 4.08 (5.09) days inpatient and 11.89 (4.96) at home. In 87.7% of the course were used the intravenous cannulae, Port-a-cath in 6.7% and Venocath in 7.8%. The intravenous access was replaced, in the 64.4% of the cases, by the nurse of the CF Unit, in the 21.4% in the emergency room of the nearest hospital and in 11.9% in primary care center. Three occasions skin reactions were reported. The parameters of pulmonary function improved significatively after HIVAT.

CONCLUSIONS

The HIVAT is a therapeutic option that, following predetermined inclusion criteria, has a low complication rate and improves pulmonary function.

[Patients with cystic fibrosis managed at the cystic fibrosis units of Madrid: cross-sectional study of 387 subjects]

BACKGROUND AND OBJECTIVE

Our objective was to describe the clinical and genetics features of patients with cystic fibrosis (CF) attended in Madrid.

PATIENTS AND METHOD

This was a descriptive, cross-sectional study of CF patients attended during 2001. Demographic, genetic, anthropometric, pancreatic insufficiency, diabetes mellitus, Pseudomonas aeruginosa colonization, lung function and body mass index (BMI) (z score) data were recorded and compared with the American CF Registry.

RESULTS

387 patients were included, most of them living in Madrid (n = 247 [63%]), 209 males (54%), with a mean age (SD) of 15.15 (10.42) years (younger than 18 years, 248, 64.24%). F508del was the most common mutation (52.8% of chromosomes) with 104 homozygous patients. Pancreatic insufficiency was present in 310 subjects (80.1%), diabetes mellitus in 30 (7.8%) and P. aeruginosa colonization in 126 (33.1%). Lung function was measured in 309 patients: mean of FEV1 and FVC predicted values (SD) was 82.5 (27.11) and 89.32 (21.89), respectively. The mean BMI z score was 0.0796 (1.18).

CONCLUSIONS

CF patients from Madrid have a good nutritional status, less P. aeruginosa colonization, less pancreatic insufficiency and better lung function than those of the American CF Registry. The lower prevalence of homozygous F508del in our population may explain, at least partly, our findings.

Estudio de la densidad mineral ósea en pacientes adultos con fibrosis quística

BACKGROUND AND OBJECTIVE

Due to recent medical advances, patients with cystic fibrosis (CF) can expect longer survival rates and, as a result, face previously unreported complications such as osteoporosis. Our goal was to determine the mineral bone density in young adult patients with CF attended in the adult CF Unit, and correlate these findings with other clinical variables of interest in this patient population.

PATIENTS AND METHOD

We carried out a transversal study from 1999 to 2002 of 34 patients with CF (19 males and 15 females. Mean age 23 years). Upon enrollment in the study, patient gender and age were recorded along with Schwachman and Brasfield scores, pulmonary function test results (spirometry) and sputum analysis, phosphorus and calcium balance, vitamin D intake, and dual energy X-ray absorptiometry (DEXA) findings of the spinal column (L2-L4) and femur.

RESULTS

54.5% of all study patients were found to have an abnormal mineral bone density. Fifteen patients met criteria for osteopenia and 3 for osteoporosis. Age, treatment with inhaled corticosteroids, and pulmonary function test results correlated with bone density.

CONCLUSIONS

DEXA scans should be performed in young adults with CF at least once during the course of their illness on the basis of the high prevalence of mineral bone density abnormalities in this population.

Polyradiculitis and Wegener's Granulomatosis

Wegener's granulomatosis is a systemic vasculitis of unknown etiology, primarily affecting the upper and lower respiratory tract and the kidneys, although there is a form restricted to the lungs. Wegener's granulomatosis occurs infrequently, with an estimated annual incidence of 8.5 cases per million. The principal symptoms at onset usually involve the upper and lower airway. The central nervous system is involved in approximately 22% of cases, but neurological signs occur infrequently among the initial clinical manifestations. Proteinase 3-specific antineutrophil cytoplasmic antibodies are useful serological markers for establishing a diagnosis, which should, however, be confirmed by a tissue biopsy of the affected organ.

[Production of tumor necrosis factor alpha and interleukin-6 by alveolar macrophages from patients with rheumatoid arthritis and interstitial pulmonary disease]

The aim of this study was to measure the production of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) by alveolar macrophages in patients with rheumatoid arthritis and interstitial lung disease (ILD). Rheumatoid arthritis patients diagnosed by ACR criteria (n = 8) with associated ILD documented by pulmonary function tests and high resolution computerized tomography scanning, and 12 healthy volunteers (6 smokers and 6 nonsmokers). We determined the spontaneous and induced production of bacterial lipopolysaccharides (LSP), TNF-alpha and IL-6 by alveolar macrophages obtained by bronchoalveolar lavage. The macrophages were isolated by Ficoll-Hypaque gradient centrifugation and plastic adherence and cultured in serum-containing medium (low endotoxin) in the presence and absence of LPS (100 ng/ml). TNF-alpha and IL-6 levels contents were determined in supernatants by ELISA. In the patient group both spontaneous and induced production of TNF-alpha were significantly higher than in controls (p < 0.01). Macrophages stimulated with LPS in patients with rheumatoid arthritis and ILD also released greater amounts of IL-6 than did those of the healthy controls. IL-6 spontaneous and induced production was significantly lower in smokers than in nonsmokers. TNF-alpha and IL-6 production in patients with rheumatoid arthritis and ILD, studied in bronchoalveolar lavage specimens reveals that alveolar macrophages are hyperreactive in these patients, who are possibly sensitized as a consequence of the inflammatory lung process inherent to the disease. Further study is needed to define the pathogenic role of these mediators.